Date post: | 17-Jan-2016 |
Category: |
Documents |
Upload: | brianna-small |
View: | 220 times |
Download: | 0 times |
Acne
Dr. Jerald E. Hurdle
Kennebec Medical Consultants
Learning Objectives
To manage the patient with acne vulgaris,
To review the clinical presentation and management of Acne Rosacea, and
To recognize acneiform rashes & folliculitis.
Case Study 1
• 28 yr old ♀
• Always had dandruff
• Using over the counter cream for facial rash
Attends Primary Care
• PCP prescribes 2.5% HC Cream
• Initially improves then returns
• PCP stops HC and rash gets much worse
• Pt demands referral to dermatology
Diagnosis: peri-oral dermatitis
Acne Vulgaris
• Common
• Puberty onwards
• Disease of pilosebaceous unit
• Gets better with time
Stages of acne. (A) Normal follicle; (B) open comedo (blackhead); (C) closed comedo
(whitehead); (D) papule; (E) pustule.
Acne Vulgaris: pathogenesis
4 factors• Presence of hormones (androgens)
• Sebaceous gland activity (due to #1)
• P. acnes (bacteria) in the hair follicle (it lives on the oil and breaks it down to free fatty acids which cause inflammation)
• Plugging of the hair follicle (abnormal keratinization of the upper portion)
Acne Vulgaris: classification
• By severity
• By type of lesions
• By distribution
Mild Moderate Severe
Acne Vulgaris: classification
• By severity
• By type of lesions
• By distribution
Papules & Pustules
Nodules & Cysts
OpenComedones
ClosedComedones
Acne Vulgaris: classification
• By severity
• By type of lesions
• By distribution
Acne Vulgaris: Rx
Patient Education • Diet
• Cleanliness
• Cosmetics
• Picking
• UV light
Acne Vulgaris: Rx
Patient EducationTreatment Response & Time
Course
• Prognosis excellent
• All treatments take up to 3 months to see improvement
• No one ever becomes zit free for the rest of their life
Acne Vulgaris: Rx Mild Disease
Topicals• Benzoyl Peroxide
• Tretinoin & adapalene
• Topical Antibiotics
Acne Vulgaris: Rx Mild Disease
Topicals• Benzoyl Peroxide
• Tretinoin & adapalene
• Topical Antibiotics
Gel, wash or cream• 5-10%• 1-2 x daily
Side effects: redness, dryness & bleaching
Acne Vulgaris: Rx Mild Disease
Topicals• Benzoyl Peroxide
• Tretinoin & adapalene
• Topical Antibiotics
Tretinoin (Retin-A)
0.025- 0.1% • 1 x Daily @ night
Adapalene (Differin)
0.1% gel or cream
1-2 x daily
SEs: dryness, redness & sun sensitivity
Acne Vulgaris: Rx Mild Disease
Topicals• Benzoyl Peroxide
• Tretinoin & adapalene
• Topical Antibiotics
Tretinoin (Retin-A)
0.025- 0.1% • 1 x Daily @ night
Adapalene (Differin)
0.1% gel or cream
1-2 x daily
SEs: dryness, redness & sun sensitivity
Acne Vulgaris: Rx Mild Disease
Topicals• Benzoyl Peroxide
• Tretinoin & adapalene
• Topical Antibiotics
Acne Vulgaris: Rx Mild Disease
Topicals• Benzoyl Peroxide
• Tretinoin & adapalene
• Topical Antibiotics
Clindamycin
1% Gel, lotion & solution
2x Daily
Erythromycin
2% gel or sol, 2x daily
Acne Vulgaris: Rx Moderate Disease
Systemics• Oral Antibiotics
• Oral Contraceptive Pills
• Spironolactone
Acne Vulgaris: Rx Moderate Disease
Systemics• Oral Antibiotics
• Oral Contraceptive Pills
• Spironolactone
Tetracycline• 250mg 2x daily• Empty stomach
Acne Vulgaris: Rx Moderate Disease
Systemics• Oral Antibiotics
• Oral Contraceptive Pills
• Spironolactone
Tetracycline• 250mg 2x daily• Empty stomach
Erythromycin• 250mg 2x daily• GI upset
Acne Vulgaris: Rx Moderate Disease
Systemics• Oral Antibiotics
• Oral Contraceptive Pills
• Spironolactone
Tetracycline• 250mg 2x daily• Empty stomach
Erythromycin• 250mg 2x daily• GI upset
Minocycline• 50-100mg 1-2x daily• Hyperpigmentation
Acne Vulgaris: Rx Moderate Disease
Systemics• Oral Antibiotics
• Oral Contraceptive Pills
• Spironolactone
Tetracycline• 250mg 2x daily• Empty stomach
Erythromycin• 250mg 2x daily• GI upset
Minocycline• 50-100mg 1-2x daily• Hyperpigmentation
Doxycycline• 50-100mg 1-2x daily• Photosensitivity
Acne Vulgaris: Rx Moderate Disease
Systemics• Oral Antibiotics
• Oral Contraceptive Pills
• Spironolactone
Acne Vulgaris: Rx Severe Disease
Acne Vulgaris: Rx Severe Disease
Isotretinoin• Refer to Dermatology• Women of childbearing potential need
adequate contraception• Check LFTS & fasting lipids• I-Pledge process bureaucratic: warn patient• Likely to require 6 months of Rx• Dry skin, cracked lips : inevitable side effects
Acne Vulgaris: Rx Severe Disease
Photography
Useful for treatment monitoring
Acne Variants: acne excoriee
• Predominantly in young women
• Comedones & papules excoriated +++
• Often underlying psych component (anxiety, OCD or personality disorder)
Acne Variants: peri-oral dermatitis
• Commoner in women• Eczematous patches
and papules around mouth
• Occasionally around eyes
• Exacerbated by topical steroids
• Treat as acne vulgaris & stop steroids
Case 2
• 33-year-old female complains of red cheeks
• Homeless, chronic alcoholic
Case 2: Physical Exam
• Red Cheeks
• Papules and pustules on the central face and nose
• NO Comedones
Case 2: Diagnosis?
• A. Systemic Lupus Erythematosus
• B. Bacterial Folliculitis with cellulitis
• C. Acne Rosacea
• D. Pellagra from nutritional deficiency
Case 2: Diagnosis?
• A. Systemic Lupus Erythematosus (no pustules)
• B. Bacterial Folliculitis with cellulitis(acute and systemic symptoms)
• C. Acne Rosacea
• D. Pellagra from nutritional deficiency (scale, diarrhea, but no pustules)
Case 2: Acne Rosacea
• Chronic inflammatory condition of the “flush” areas of the face (nose, cheeks > brow, chin)
• F > M
• Middle age (30-50)
• Affected persons blush easily
Case 2: Question 2
• Which of the following might trigger this patient’s rosacea? A. AlcoholB. Heat/Hot BeveragesC. SunlightD. Hot, spicy foodsE. All of the above
Case 2: Question 2
• Which of the following might trigger this patient’s rosacea?
A. AlcoholB. Heat/Hot BeveragesC. SunlightD. Hot, spicy foodsE. All of the above
Acne Rosacea: triggers
• Alcohol
• Sunlight
• Hot Beverages (heat)
• Hot, Spicy food
• If it makes you flush it can flare rosacea
• Rosacea is NOT related to androgens!!
Acne Rosacea: clinical features
• Erythema and Telangiectasias
• Papules and Pustules (NO COMEDONES!)
• Rhinophyma (W.C. Fields nose)
• Ocular Rosacea (keratitis, blepharitis, conjunctivitis)
Acne Rosacea
Acne Rosacea
Acne Rosacea
Acne Rosacea
Acne Rosacea
Acne Rosacea Treatment
• Medical treatment only effective for the papular and pustular component
• Topical Antibiotics (metronidazole)
• Topical Sulfur
• Oral Antibiotics (tetracyclines)
• Therapy is suppressive and may be required lifelong
Acne Rosacea: Surgical Treatment
• Laser therapy can help the telangiectasias and the rhinophyma, once the papulopustular component is controlled.
Steroid Rosacea
• Topical Steroids may exacerbate or induce an acneiform eruption resembling rosacea
• Treatment: Stop the topical steroids; give oral tetracyclines.
• Never treat central facial papular eruptions with topical steroids. It may be rosacea which will flare severely when the topical steroids are stopped
Case 3
Acneiform Eruptions: Drugs
• Systemic/topical steroids
• Anabolic steroids
• Lithium
• Phenytoin (Dilantin®)
• Epidermal growth factor receptor inhibitors
Acneiform Eruptions: Acne Keloidalis Nuchae & Pseudofolliculitis Barbae
• Predominantly affects men of African descent
• Due to ingrowing hairs
• Avoid shaving
• Treat as acne
Folliculitis
• Confined to hair follicles• No comedones• Lesions tend to
monomorphic• Often itchy• Common causes Staph,
Pityriasporum
• If HIV positive, consider eosinophilic folliculitis
Learning Objectives
To manage the patient with acne vulgaris,
To review the clinical presentation and management of Acne Rosacea, and
To recognize acneiform rashes & folliculitis.